Selective neurotomy of the sciatic nerve branches to the hamstring muscles: An anatomical study.

BACKGROUND

Hamstring spasticity can bring about a flexion deformity of the knee, liable to cause disability. Surgical treatment by selective neurotomies of the sciatic nerve branches leading to the hamstring muscles may then be indicated. Few studies have investigated the precise origin of these branches on the sciatic nerve, describing the innervation pattern of the hamstring muscles. Further anatomical data are needed to enhance surgical techniques in neurotomies of the sciatic nerve branches, to define the best incision and surgical approach and what section and length of the SN need to be exposed. Therefore, we performed an anatomical study to: (1) define a surgical approach to perform selective neurotomies of the sciatic nerve branches for hamstring spasticity?(2) whether the anatomical variants of the hamstring innervation have been identified?

HYPOTHESIS

Our anatomical data could lead to the definition of an approach to the sciatic nerve for the purpose of selective neurotomy.

MATERIAL AND METHODS

Twenty posterior compartments of the thigh were dissected. We counted each branch of the sciatic nerve leading to the hamstring and described their arising point using the centre of the lateral surface of the great trochanter and the lower edge of the gluteus maximus muscle as main anatomical landmarks. We also described the presence of branch divisions and their muscular penetrating points.

RESULTS

The mean distances between the center of the lateral surface of the great trochanter and the emergence of branches from the SN were: 2.2±3.6cm (-5 to 9cm) for the long head of the biceps femoris muscle, 2.3±3cm (-4 to 10cm) for the semitendinosus muscle, and 2.2±3cm (-5 to 8cm) for the semimembranosus muscle. No branches originated from the sciatic nerve below the lower edge of the gluteus maximus muscle. In summary the branches innervating the hamstrings originated from the SN within an interval of 15cm (5cm above and 10cm below the centre of the lateral surface of great trochanter). The average number of sciatic nerve branches for the hamstring muscles was 4.7 (minimum: 3; maximum: 6) with 1.8 branches for the long head of the biceps [1 in 7/20 (35%), 2 in 10/20 (50%), and 3 in 3/20 (15%)], 1.5 branches for the semitendinosus [1 in 11/20 (55%) and 2 in 9/20 (45%)], 1.4 branches for the semimembranosus [1 in 12/20 (60%) and 2 in 8/20 (40%)]. No branches had a common origin with cutaneous nerves.

DISCUSSION

This anatomical study enabled us to propose an approach to exposing the sciatic nerve in order to perform a selective neurotomy: horizontal cutaneous incision on the gluteal fold, incision of the lower edge of the gluteus maximus, exposure of the sciatic nerve to a distance of 10cm below the great trochanter, and visualization of the nerve branches to the hamstring muscles. Exposure of the nerve above the great trochanter is not necessary because the branches which emerge from the SN above the great trochanter are still contiguous with the SN.

LEVEL OF EVIDENCE

IV: prospective study without control.